$1,900 individual / $3,800 family. Does not apply to preventive care and prescription drugs. What is the overall deductible?

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Paramount Insurance Company: Paramount HMO Silver

Coverage Period: 1/1/2014 - 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type:HMO 

This is only a summary.

If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.paramount insurancecompany.com or by calling 1-800-462-3589

Important Questions Answers Why this Matters:

What is the overall deductible?

$1,900 individual / $3,800 family. Does not apply to preventive care and prescription drugs.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy plan or plan document to see when the

deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other

deductibles for specific services?

Yes, $100 individual / $200 family

for prescription drug expenses. You must pay all of the costs for these services up to the specific before this plan begins to pay for these services. deductibles amount

Is there an out-of-pocket-limit on my expenses?

Yes, for in-network providers

$6,350 individual/$12,700 family. No, for out-of-network providers.

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in the out-of-pocket limit?

Premiums, balance-billed charges, and out-of-network services this

plan doesn't cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Is there an overall annual limit on what the

plan pays? No

The chart starting on page 2 describes any limits on what the plan will pay for specific

covered services, such as office visits.

Does this plan use a network of providers?

Yes. See

www.paramountinsurance company.com/findaprovider or call 1-800-462-3589 for a list of participating providers.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to

see a specialist? No, you don't need a referral tosee a specialist. You can see the specialist you choose without permission from this plan.

Are there services this

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Paramount Insurance Company: Paramount HMO Silver

Coverage Period: 1/1/2014 - 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type:HMO 

Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service

Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if

the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200.  This may change if you haven’t met your deductible.

• The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

• This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical

Event Services You May Need

Your Cost If You Use an In-network Provider

Your Cost If You Use an

Out-of-network ProviderLimitations & Exceptions If you visit a health

care provider's office or clinic

Primary care visit to treat an injury or illness $35 Copay/visit Not covered ---None---Specialist visit $70 Copay/visit Not covered

---None---Other practitioner office visit 40% Coinsuranceafter deductible Not covered Spinal Manipulation limited to 12visits per Calendar year. Preventive care/screening/immunization No Charge Not covered

---None---If you have a test Diagnostic test (x-ray, blood work)

40% Coinsurance

after deductible Not covered ---None---Imaging (CT/PET scans, MRIs) 40% Coinsuranceafter deductible Not covered

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---None---Paramount Insurance Company: ---None---Paramount HMO Silver

Coverage Period: 1/1/2014 - 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type:HMO 

Common Medical

Event Services You May Need

Your Cost If You Use an In-network Provider

Your Cost If You Use an

Out-of-network ProviderLimitations & Exceptions If you need drugs to

treat your illness or condition

More information about

prescription drug coverage is available at www.paramount insurancecompany.com.

Generic drugs Retail: $15 AvgCopay. Mail Order:

$45 Avg Copay Not covered

Coverage limited to a 30 day supply (retail); 90 day supply (mail order). Subject to Deductible.

Preferred brand drugs Retail: $50 Copay.Mail Order: $125

Copay Not covered

Same as Generic drugs. Subject to Deductible.

Non-preferred brand drugs Retail: $100 Copay.Mail Order: $300

Copay Not covered

Same as Generic drugs. Subject to Deductible.

Specialty drugs 4with a maximum of0% Coinsurance

$200 Not covered

Specialty drugs are available through a limited specialty network and not available through mail order program. Subject to Deductible.

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center) 40% Coinsuranceafter deductible Not covered ---None---Physician/surgeon fees 40% Coinsuranceafter deductible Not covered

---None---If you need immediate medical attention

Emergency room services 40% Coinsuranceafter deductible / visit

40% Coinsurance after deductible /

visit ---None---Emergency medical transportation 40% Coinsuranceafter deductible Not covered ---None---Urgent care $90 Copay/visit Not covered

---None---If you have a hospital stay

Facility fee (e.g., hospital room) 40% Coinsuranceafter deductible Not covered

---None---Physician/surgeon fee 40% Coinsuranceafter deductible Not covered One (1) Inpatient visit per day perPhysican or other Professional Provider

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Paramount Insurance Company: Paramount HMO Silver

Coverage Period: 1/1/2014 - 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type:HMO 

Common Medical

Event Services You May Need

Your Cost If You Use an In-network Provider

Your Cost If You Use an

Out-of-network ProviderLimitations & Exceptions If you have mental

health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services $70 Copay/visit Not covered ---None---Mental/Behavioral health inpatient services 40% Coinsuranceafter deductible Not covered ---None---Substance use disorder outpatient services $70 Copay/visit Not covered ---None---Substance use disorder inpatient services 40% Coinsuranceafter deductible Not covered

---None---If you are pregnant

Prenatal and postnatal care No Charge Not covered ---None---Delivery and all inpatient services 40% Coinsuranceafter deductible Not covered

---None---If you need help recovering or have other special health needs

Home health care 40% Coinsuranceafter deductible Not covered 100 Visit(s) per Year

Rehabilitation services 40% Coinsuranceafter deductible Not covered Inpatient limited to 60 days per year.Outpatient therapy services limited to 20 visits per therapy type.

Habilitation services 40% Coinsuranceafter deductible Not covered Habilitative services benefits shall bedetermined by the individual plans. Skilled nursing care 40% Coinsuranceafter deductible Not covered 90 Days per Year

Durable medical equipment 40% Coinsuranceafter deductible Not covered ---None---Hospice service 40% Coinsuranceafter deductible Not covered

---None---If your child needs dental or eye care

Eye exam $70 Copay/visit Not covered 1 Visit(s) per Year

Glasses No Charge afterdeductible Not covered Lenses and contacts: 1 Item(s) perYear. Frames: 1 Item(s) per 2 Years. Dental check-up Not covered Not covered

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---None---Paramount Insurance Company: ---None---Paramount HMO Silver

Coverage Period: 1/1/2014 - 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type:HMO 

Excluded Services & Other Covered Services

Services Your Plan Does Not Cover(This isn't a complete list. Check your policy or plan document for other excluded services .) • Acupuncture

• Dental care (Adult) • Long-term care

• Bariatric surgery • Dental care (child) • Routine foot care

• Cosmetic surgery • Hearing aids

• Weight loss programs

Other Covered Services(This isn't a comlete list. Check your policy or plan document for other covered services and your costs for these services.)

• Chiropractic care • Private-duty nursing

• Infertility treatment • Routine eye care (Adult)

• Non-emergency care when traveling outside

the U.S.

Your Rights to Continue Coverage

Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if:

• You commit fraud

• The insurer stops offering services in the State • You move outside the coverage area

For more information on your rights to continue coverage, contact the insurer at 1-800-462-3589. You may also contact your state insurance department at The Ohio Department of Insurance, 50 W. Town Street Third Floor - Suite 300 Columbus, Ohio 43215 Phone:(800) 686-1526.

Your Greivance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: The Ohio Department of Insurance, 50 W. Town Street Third Floor - Suite 300 Columbus, Ohio 43215 Phone:(800) 686-1526.

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Paramount Insurance Company: Paramount HMO Silver

Coverage Period: 1/1/2014 - 12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family | Plan Type:HMO 

Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage." This plan or policy does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?

The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-800-462-3589

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Paramount Insurance Company: Paramount HMO Silver

Coverage Period: 1/1/2014 - 12/31/2014

Coverage Examples Coverage for: Individual/Family | Plan Type:HMO 

About these Coverage

Examples:

These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

This is not a cost

estimator.

Don't use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these

examples, and the cost of that care will also be different.

See the next page for important information about these examples.

Having a baby

(normal delivery)

Amount owed to providers: $7,540 ■ Plan pays $3,370

Patient pays $4,170

Sample care costs:

Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900

Anesthesia $900

Laboratory tests $500

Prescriptions $200

Radiology $200

Vaccines, other preventive $40

Total $7,540

Patient pays:

Deductibles $1,920

Copays $70

Coinsurance $2,030

Limits or exclusions $150

Total $4,170

Managing type 2 diabetes

(routine maintenance of a well-controlled condition)

Amount owed to providers: $5,400 ■ Plan pays $2,310

Patient pays $3,090

Sample care costs:

Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700

Education $900

Laboratory tests $500 Vaccines, other preventive $40

Total $5,400

Patient pays:

Deductibles $2,000

Copays $840

Coinsurance $170

Limits or exclusions $80

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Paramount Insurance Company: Paramount HMO Silver

Coverage Period: 1/1/2014 - 12/31/2014

Coverage Examples Coverage for: Individual/Family | Plan Type:HMO 

Questions and answers about the Coverage Examples:

What are some of the

assumptions behind the

Coverage Examples?

• Costs don’t include premiums.

• Sample care costs are based on national

averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.

• The patient’s condition was not an excluded

or preexisting condition.

• All services and treatments started and

ended in the same coverage period.

• There are no other medical expenses for

any member covered under this plan.

• Out-of-pocket expenses are based only on

treating the condition in the example.

• The patient received all care from

in-network providers.  If the patient had received care from out-of-network

providers, costs would have been higher.

What does a Coverage Example

show?

For each treatment situation, the Coverage Examples helps you see how deductibles,

copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn't covered or payment is limited.

Does the Coverage Example predict

my own care needs?

No

. Treatments shown are just examples. The

care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict

my future expenses?

No

. Coverage Examples are not cost

estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Can I use Coverage Examples to

compare plans?

Yes

. When you look at the Summary of

Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should

consider when comparing plans?

Yes

. An important cost is the premium

you pay.  Generally, the lower your

premium, the more you’ll pay in out-of-pocket costs, such as copayments,

deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

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